CIO Designation CIO Designation Application Form DESIGNATION PROCESS This application must be completed and submitted to the CIO Association of Canada, Designation Committee for review. This review will involve verification of all submitted information and response regarding CIO Designation obtainment to the applicant will be within 30 days. Details subject to change. APPLICANT INFORMATION Dropdown March, 2024 Program Start Date Name Name First Name First Name Last Name Last Name Primary Telephone Primary Telephone Secondary Telephone Secondary Telephone Primary Email Primary Email Secondary Email Secondary Email CURRENT EMPLOYER INFORMATION Employment Employment Employer Name Employer Name Job Title Job Title Employer Address Employer Address City City Province Province Postal Code Postal Code Industry sector Industry sector Type of organization Type of organization To whom do you report? To whom do you report? What is their title? What is their title? Do you have any direct reports? YesNo Do you have any direct reports? If yes, how many? If yes, how many? Please describe your current role and the specifics of your 3 years of IT leadership including any past employers and roles Please describe your current role and the specifics of your 3 years of IT leadership including any past employers and roles REFERENCES Please provide the names and contact information of two references that can attest to your 3 years of leadership experience Reference #1 Name of Reference Name of Reference First Name of Reference First Name of Reference Last Name of Reference Last Name of Reference Organization Organization Title Title Relationship to applicant Relationship to applicant Telephone Telephone Email Email Reference #2 Name of Reference Name of Reference First Name of Reference First Name of Reference Last Name of Reference Last Name of Reference Organization Organization Title Title Relationship to applicant Relationship to applicant Phone Telephone Email Email FEES An active CIOCAN membership is a requirement for maintaining CIO Designation by the CIO Association of Canada. A full annual CIOCAN membership fee of $750 is required. Payment is due upon completion of your application review. DECLARATION I hereby certify that all statements on the application and in any material filed in support hereof are true, correct and complete, and all material information has been disclosed. I also have read, and agree to comply with the CIO.D Code of Conduct (link here). I understand that the CIO Association of Canada may reject my application for CIO.D Designation based on any of the information in this application found to be inaccurate or misleading. I also pledge to conduct myself in a manner of integrity, honesty and respect for individuals in the CIO Association of Canada community. If I am found to act in a manner contrary to the aforementioned values and in particular the CIO.D Code of Conduct, I understand that I may lose my Designation as a CIO. Signature Clear Signature (Draw or Type) Date Date Upload Current CV (accepted file types: .doc and .pdf) Drop a file here or click to upload Choose File Maximum file size: 52.43MB Upload Current CV (accepted file types: .doc and .pdf) APPLICATION PACKAGE SUBMISSION CHECKLIST Checkboxes * Completed Application Form Current CV (accepted file types: .doc and .pdf) If you are human, leave this field blank. Submit
